Technology Errors & Omissions Insurance Application
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- Belinda Hancock
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1 3660 N Lake Shore Dr, Suite 2602, Chicago Technology Errors & Omissions Insurance Application General Information Named Insured: Entity Type: Primary Address, City, State, Zip: Mailing Address, City, State, Zip: Contact Person: Phone / Fax: Website: Year Business Established: Requested Coverage Limits Per Glitch $ Aggregate $ Self-Insured Retention $ Current E&O Coverage, if any Effective Date Retroactive Date Insurance Company 1 Submit to Johnsonese Brokerage LLC, info@johnsonese.com, Fax:
2 Expertise Total Number of Employees Average Years of Professional Experience in Technology Services Number of Independent Contactors under contract Financial Projections for the Fiscal Period Total revenue $ Total revenue from foreign sales $ Operating Expenses $ Describe the applicant's business operations and products in detail: Revenue by Type of Technology Products/ Services Hardware Products/ Services: % Manufacturing of Hardware Products/ Components for Others (includes firmware for the hardware products the applicant manufactures, as well as, revenue generated from installation/ integration/ maintenance of hardware products the applicant manufactures.) Resale of Hardware Products Manufactured by Others Installation/ Integration/ Maintenance of Hardware Products Manufactured by Others (includes value added reseller (VAR) operations in which the applicant purchases hardware and prepackaged software products for their customer with the added service of installing and configuring the hardware and software to customer specifications) Software Products/ Services: % Packaged Software Development and Sales (packaged software is software in which the core software code is the same for every customer but may include minor customizations to meet preferences/ needs of the customer; please include revenue generated from installation/ integration/ maintenance of the applicant s packaged software) Custom Programming Services and Software Development (this does not include minor customization to applicant s packaged software application; this category pertains to programming for specific projects that are unique to each individual customer) 2 Submit to Johnsonese Brokerage LLC, info@johnsonese.com, Fax:
3 Revenue by Type of Technology Products/ Services (continued) Software Products/ Services (continued): % Software Installation/ Integration/ Maintenance of Software Products of Others (installation, maintenance, and integration of software developed by others; this type of service does not include the installation, maintenance or integration of software product developed by the applicant) Application Service Provider (ASP) Services (An ASP is a company that manages and distributes software-based services and solutions to customers across a wide area network from a central data center)* Web Site Design Communication and Connectivity Services: % Internet Access/ Web Site & Data Hosting/ IT Connectivity Services (this category does not include voice telecommunication services see separate category below) Telecommunication Services (wireline, wireless, voice over internet protocol - VOIP, local/long distance telephone services) Internet Search Engine & Portal Services Other Information Technology Services: % IT Network and Systems Management/ Systems Outsourcing (this category includes those companies engaged in managing the information technology network of others including active network operations services, resolving network system issues, Help Desk functions, etc.) Information Security Services (this category includes those companies engaged in specialized information security services including it network penetration testing, it network assessments, information security assessments, it network intrusion detection services, etc.) Other Information Technology Services (continued): % Consulting Services (this category is for applicants that strictly provide advice to their customers on information technology; this category does not include consulting on products and services that offered by the applicant; the revenue for consulting services on products and services offered by the applicant should be included in the category for the specific product or service; please contact the underwriter if the applicant provides consulting services on anything other than information technology products and services) IT Staffing Services (placement of it personnel at the direction & control of others on a time & materials basis) Other: % Describe fully: Total 100 *Does the applicant provide ASP services for software developed by the applicant? *Does the applicant provide ASP services for software developed by others? Yes/ No 3 Submit to Johnsonese Brokerage LLC, info@johnsonese.com, Fax:
4 Applications/ End Uses Training Education (this category would include products and services that train or educate others on technology) Physical Process Applications/ End Uses (this category would include technology that is involved with the physical control or operation of machinery, equipment, vehicles, etc. This includes manufacturing equipment, agriculture/mining equipment, watercraft, automotives, aircraft/spacecraft, trains, factory automation, robotics, CAM Computer Aided Manufacturing, utility/natural resource processing equipment, chemical processing equipment, etc.) Medical Purpose Applications/ End Uses (this category includes technology that is utilized to perform medical diagnostics, medical therapeutics, patient care/ treatment, medical alert, life sciences/ biotechnology research & development, clinical trial management, etc. This category is not intended for business operation applications/ end uses such as medical billing, patient scheduling, general office management, and supply chain management for medical service providers.) Military/ Defense Applications/ End Uses (this category includes guidance systems technology, vehicle/ equipment tracking systems, weapon targeting systems, warfare systems, friendly versus hostile identification systems, warning systems including radar, sonar, etc. This category does not include general office management, accounting, supply chain management, non-combat related activities performed for Military customers.) Fire/ Physical Security/ Emergency Applications/ End Uses (this category includes information technology that is utilized to detect, notify and/or respond to emergency and/or physical security type applications including alarm systems, fire suppression technology/controls, physical security devices, emergency response technologies, scientific/weather warning systems, seismic activity measurement devices, etc.) Information & Computer Systems Security Advice/ Products (this category includes consulting and products related to intrusion detection, penetration testing, vulnerability assessment, virus/malicious code detection & removal, etc. This category does not include system integration activities where the applicant may be involved with the installation of security software manufactured by others) Architect/ Engineering/ CAD (Computer Aided Design) Applications/ End Uses (this category includes technology products and services that are utilized for architectural and engineering design purposes. These products are utilized to assist in the design of buildings, bridges, physical structures, products, manufactured goods, electronics, etc.) Communication Services (this category includes voice and data communication services including information network connectivity, internet access services, local & long distance telephone services, Voice over Internet Protocol (VoIP) service, wireless communication service, etc.) Check if applicable 4 Submit to Johnsonese Brokerage LLC, info@johnsonese.com, Fax:
5 Applications/ End Uses (continued) Information Network management and Maintenance Services (this category includes information network management and maintenance, as well as, installation and integration of computer hardware and software for others). Homeland Security Applications/ End Uses (this category includes technology products and services that are specifically designed to assist in Homeland Security initiatives of the United States Government. This may include applications/end uses that assist the government with detection, tracking, notification, response, etc. to a situation that threatens the security of the United States.) Human Resources (this category includes technology products and services that perform or assist with performing human resource functions benefits enrollment, employee performance monitoring/management, etc.) Financial Software funds transfer, trading, financial monitoring (this category includes technology products and services that are involved in real-time financial transactions and analytics. This includes financial asset management applications, such as, investment modeling, stock/bond trading, funds transfer, financial institution operational applications, etc.) Accounting Software (this category includes technology products and services that perform general accounting functions. This category does not include applications that manage financial transactions that are realtime sensitive see Financial Software) Pollution/ Environmental Testing & Remediation (this category includes technology products and services that are utilized to detect, monitor, analyze environmental conditions and/or assist with remediation activities) Administrative (this category includes technology products and services that are utilized to conduct general business functions including billing, sales, marketing, etc. including Enterprise Resource Planning (ERP), Supply Chain Management(SCM), and other logistics applications utilized for business operations) Internet Content for Others Other (describe fully): Check if applicable Sub-Contracts, if any Outsourced/ Sub-contracted Service Purpose 5 Submit to Johnsonese Brokerage LLC, info@johnsonese.com, Fax:
6 Sub-Contracts, if any (continued) Do you utilize content or services of others in your operations or technology services/ products? If yes, do you obtain appropriate written consents, releases and rights for content or services provided by others? Yes/ No Other Do you perform/ provide accounting, architectural, engineering, legal, medical, health-related, nutritional or insurance advice/content/services for others? In the past three years, have you had any claims resulting from your technology services/products or are you aware of any situation or circumstance that could give rise to a claim? In the past three years, have you sued a customer for failure to pay for products or services rendered? Please explain any yes answers: Yes/ No Customers & Contracts Average customer contract size $? Average length/term of customer contract? Who is your largest customer? What is your largest customer contract size $? What is the length/term of your largest customer contract? What percentage of your work, services or products are sold or executed using non-standard contracts or contracts supplied by the customer? Standard Contract Provisions Select all that apply Disclaimer of liability Limitation of Liability Warranty Disclaimers Remedy for Disputes or Breaches Indemnification/ hold harmless agreements Arbitration Choice of Law Force Majeure None of the Above 6 Submit to Johnsonese Brokerage LLC, info@johnsonese.com, Fax:
7 Customer Data Are you responsible for your customer's data as part of the technology services you provide? If yes, select how often do you back up software and applicable data essential to the customer's operations: If Other, please describe: If Do not perform back-up, please explain: Daily Weekly Monthly Other Do not perform back-up Website/ Operations Select all that apply Business to Business e-commerce transactions (i.e. the exchange of products/ services between business via the internet) Business to Consumer e-commerce transactions (i.e. the exchange of products/ services between business and consumers via the internet) Exchange to Exchange e-commerce transactions (i.e. the exchange of information between web sites that act as brokers for products/ services exchange between businesses) Auction Services Downloadable music, videos, previously published materials or other types of copyrighted materials Children focused content (site dedicated to entertaining children that may include capabilities, chat rooms, game/content downloads, marketing/selling of consumer goods) Gaming/ Gambling Advertising of products/ services other than your own Links to web sites of others including deep linking and meta tags Bulletin Boards None of the Above 7 Submit to Johnsonese Brokerage LLC, info@johnsonese.com, Fax:
8 SIGNING THIS APPLICATION DOES NOT BIND THE APPLICANT FIRM OR THE COMPANY TO COMPLETE THE INSURANCE. APPLICATION MUST BE SIGNED AND DATED BY AN OWER, PARTNER OR OFFICER OF THE APPLICANT FIRM. Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied. APPLICANT'S STATEMENT: I, being duly authorized, have read the above application and declare to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to the Company to issue the policy for which I am applying. (Kansas: This does not constitute a warranty). Authorized Signature: Title: Print Name: Date: 8 Submit to Johnsonese Brokerage LLC, info@johnsonese.com, Fax:
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